How Kaiser Permanente uses video ethnography of patients for quality improvement, such as in shaping better care transitions.

Keeping patients and caregivers at the center of quality improvement is critical. Kaiser Permanente's Care Management Institute adapted video ethnography to achieve this aim, using video to capture interviews with-and observations of-patients and caregivers, identify patient-centered improvement opportunities, and communicate them effectively to clinical and administrative leaders and front-line staff. This method is particularly effective for helping understand the needs of frail elders, patients nearing the end of life, those with multiple chronic conditions, and other vulnerable people who are not well represented in focus groups and patient advisory councils. As part of an initiative to improve care transitions for elders with heart failure, video ethnography contributed to greatly reduced thirty-day hospital readmission rates, helping reduce readmissions at one medical center from 13.6 percent to 9 percent in six months. It also helped improve the reliability of the readmissions reduction program. When embedded within an established quality improvement framework, video ethnography can be an effective tool for innovating new solutions, improving existing processes, and spreading knowledge about how best to meet patient needs.

Rapid spread of complex change: a case study in inpatient palliative care.

BACKGROUND: Based on positive findings from a randomized controlled trial, Kaiser Permanente's national executive leadership group set an expectation that all Kaiser Permanente and partner hospitals would implement a consultative model of interdisciplinary, inpatient-based palliative care (IPC). Within one year, the number of IPC consultations program-wide increased almost tenfold from baseline, and the number of teams nearly doubled. We report here results from a qualitative evaluation of the IPC initiative after a year of implementation; our purpose was to understand factors supporting or impeding the rapid and consistent spread of a complex program. METHODS: Quality improvement study using a case study design and qualitative analysis of in-depth semi-structured interviews with 36 national, regional, and local leaders. RESULTS: Compelling evidence of impacts on patient satisfaction and quality of care generated 'pull' among adopters, expressed as a remarkably high degree of conviction about the value of the model. Broad leadership agreement gave rise to sponsorship and support that permeated the organization. A robust social network promoted knowledge exchange and built on an existing network with a strong interest in palliative care. Resource constraints, pre-existing programs of a different model, and ambiguous accountability for implementation impeded spread. CONCLUSIONS: A complex, hospital-based, interdisciplinary intervention in a large health care organization spread rapidly due to a synergy between organizational 'push' strategies and grassroots-level pull. The combination of push and pull may be especially important when the organizational context or the practice to be spread is complex.

Coordination of diabetes care in four delivery models using an electronic health record.

BACKGROUND: Care coordination is essential to effective chronic care, but knowledge of processes by which health care professionals coordinate their activities when caring for chronically ill patients is limited. Electronic health records (EHRs) are expected to facilitate coordination of care, but whether they do so completely-and under what conditions-is not well understood. OBJECTIVES: To identify processes by which providers worked together to provide care using an EHR and to examine factors supporting coordination of care. DESIGN: Qualitative multiple case study in 4 sites with diverse care delivery models, using semi-structured in-person interviews with 46 physicians and staff and telephone interviews with 65 adult patients with diabetes. SETTING: Four Kaiser Permanente medical centers. RESULTS: Across all care models, physicians and staff acted sequentially as loosely coupled links in a chain, relying on EHR-enabled informational continuity to coordinate care. Of providers, 94% were highly satisfied with the availability of patient information, and 89% of patients were satisfied or very satisfied with the coordination of their care. However, 6 of 65 patients described experiences of uncoordinated care, and 5 of 12 primary care providers identified coordination issues. These pertained to unreconciled differences of opinion, conflicting role expectations, and discipline-specific views of patient needs. CONCLUSIONS: Diabetes care can be coordinated across providers, but some coordination issues persist despite the informational continuity provided by an EHR. Multidisciplinary care teams should be alert to potential coordination challenges, and possible solutions should be explored, including longitudinal care planning with structured communications at key points in care.